Climate change meets hypertension care in a South African framework

Researchers working in Limpopo Province have built a structured framework that translates the everyday experiences of hypertensive patients — sweltering summers, disrupted clinic visits, improvised cooling tricks — into seven formal adaptation strategies intended for primary healthcare planning. The work, published in Frontiers in Public Health, is among the first attempts to move beyond documenting climate-related health impacts and to hand clinicians and policymakers an operational playbook for one of the world’s most common chronic conditions.

The research team, based at the University of Limpopo, chose a mixed-methods convergent parallel design, collecting quantitative and qualitative data at the same time and then integrating the results. On the quantitative side, 244 hypertensive patients completed self-developed questionnaires across selected districts of Limpopo Province. Using systematic sampling, the team drew from a target population of 400 patients who had been on hypertension treatment for at least three years; the sample size of 244 was calculated with Slovin’s formula at a 5% margin of error and 95% confidence level. In parallel, 15 patients took part in semi-structured interviews recruited through homogeneous purposive sampling, with recruitment continuing until data saturation — the point at which no new codes or themes emerged. Quantitative data were analysed in SPSS version 28, qualitative data with Tesch’s eight-step method, and the two strands were merged in a joint display to identify convergence, divergence and expansion.

The numbers that emerged are striking. Among respondents, 84% reported very hot summer temperatures, and 65.2% said they noticed changes in their blood pressure during extreme heat. Divergence appeared in knowledge: 58% of patients were unaware of appropriate cooling techniques. The interviews added texture and practical detail, revealing coping strategies already in use — increased water intake, dietary changes, consumption of traditional foods and the use of indigenous remedies. The study also identified broader gaps: limited awareness of climate change and its health impacts, difficulties managing hypertension during extreme temperatures, inconsistent coping practices, and an absence of structured adaptation guidance. Together, these findings formed the empirical foundation for everything that followed.

To convert patient experience into strategy, the researchers anchored their work in two established frameworks. Roy’s Adaptation Model (RAM) provided the theoretical lens, treating hypertensive patients as active participants who must adapt continuously to changes in their internal and external environments. Thompson’s Five Stage Strategy Development Framework supplied the process architecture, moving from vision and mission through objectives, strategy crafting, and finally monitoring and evaluation. Stage 2 translated the merged findings into five strategic objectives: strengthening clinical capacity, enhancing patient education and awareness, improving service delivery systems, promoting early warning and preparedness systems, and deepening community engagement and partnerships.

Stage 3 and Stage 4 turned those objectives into seven concrete strategies. Strategy 1 calls for climate-informed healthcare services, embedding climate awareness into routine hypertension care, facility planning and provider training. Strategy 2 addresses self-care management during extreme heat: hydration guidance, cooling strategies, recognition of heat-related symptoms and safe outdoor practices. Strategy 3 covers behavioural and lifestyle interventions, including diet modification, physical activity tailored to environmental conditions, stress management and medication adherence support. Strategy 4 focuses on information and coping — access to reliable climate-health information, blood pressure monitoring, emergency awareness and peer support. Strategy 5 centres on patient education and empowerment, from self-monitoring to emergency response knowledge. Strategy 6 targets climate-resilient lifestyle education for healthcare workers and home-based carers, while Strategy 7 builds emergency preparedness around weather alerts, response planning, medication continuity and post-event follow-up care.

The physiological reasoning behind these strategies is grounded in established climate-health mechanisms. Extreme heat causes peripheral vasodilation, increases cardiovascular workload and may contribute to blood pressure fluctuations; it also raises dehydration risk as the body relies on sweating and evaporation for thermoregulation, and when environmental temperatures become excessively high, thermoregulation itself becomes less effective. Extreme cold works in the opposite direction, contributing to vasoconstriction, elevated blood pressure and cardiovascular complications including myocardial infarction and stroke. Cold conditions can also affect indoor air quality through certain heating practices, potentially adding respiratory irritation and cardiovascular stress. The emergency preparedness strategy responds to evidence that heatwaves, floods, droughts and cold spells can disrupt healthcare access and generate physiological and psychosocial strain, which is why medication continuity and structured post-event follow-up feature so prominently.

Before finalisation, the draft strategies underwent validation through a one-round Modified Delphi consultation. Six experts were purposively selected — two physicians, two professional nurses and two academics, all with more than 15 years of professional experience — and rated 24 criteria across four domains: Goals and Practice, Context of the Coping Strategies, Explanation of the Coping Strategies, and Evidence to Support the Coping Strategies. Each expert scored every criterion on a two-point scale, yielding 144 expert-item ratings. Of these, 143 (93.3%) were affirmative, with a single negative response. Twenty-three criteria achieved 100% agreement and one achieved 83.3%, meaning all 24 criteria met the predefined 80% consensus threshold. Qualitative expert feedback also drove refinements: panellists recommended strengthening implementation guidance for Strategy 5, incorporating supporting evidence into the patient education strategy, applying adult education principles, and giving greater weight to rural resource constraints, health literacy and potential overlap between Strategies 1 and 4.

The authors are careful about what the Delphi result does and does not demonstrate. Because the revised strategies were not returned to the experts for a second round, the reported consensus applies to the draft strategies assessed during the Modified Delphi round and should not be read as consensus on the subsequently refined version. Effectiveness, too, remains an open question: the validation established expert agreement on clarity, relevance, feasibility, practicality and applicability, but the strategies’ impact can only be established through subsequent implementation and empirical evaluation in real-world healthcare settings. Stage 5 of the framework therefore lays out a monitoring and evaluation plan, assessing fidelity, reach, acceptability, feasibility and uptake through routine records, implementation checklists, attendance registers, provider reports and patient feedback, while effectiveness evaluation would track changes in patients’ knowledge, self-management practices, preparedness, medication adherence and blood pressure monitoring.

What gives the framework its broader ambition is the systems perspective layered on top of individual coping. Alongside RAM and the Thompson framework, the authors invoke Measurement for Change (M4C) to ensure strategies integrate across patients, providers, facilities, communities and public health structures, with emphasis on measurement, collaboration, learning and sustainability. Implementation, they argue, requires collaboration among healthcare services, environmental and meteorological agencies, disaster management structures, local government and community organisations — a deliberate shift from fragmented, disease-specific interventions toward cross-sectoral public health planning. The framework is explicitly aligned with Sustainable Development Goal 3 on health and Goal 13 on climate action, and the authors position it as a transferable process for other chronic disease programmes in climate-vulnerable, resource-constrained settings, not only for hypertension in Limpopo.

The limitations section is candid, and it matters. The findings are context-specific to selected districts of Limpopo Province and should be generalised cautiously to regions with different climatic, socioeconomic, cultural and healthcare contexts. The cross-sectional quantitative data relied largely on self-reported experience, so they cannot establish causal or long-term relationships between climate exposures, coping strategies and hypertension outcomes. The Delphi validation reflected expert consensus rather than clinical effectiveness, and the framework’s implementation feasibility, scalability, sustainability, cost-effectiveness and impact on blood pressure control remain untested. Future research, the authors suggest, should use longitudinal and implementation-focused designs, objective clinical and environmental data, broader stakeholder participation and multi-site validation. Even so, the study marks a shift in the climate-health conversation: from cataloguing risks to designing and refining practical adaptation strategies, whose effectiveness in real-world healthcare settings remains to be evaluated.

Subject of Research: Development and expert validation of climate change adaptation strategies for hypertensive patients in Limpopo Province, South Africa

Article Title: Integrating climate change adaptation into hypertension care: an evidence based framework for climate resilient primary healthcare and public health planning in Limpopo Province, South Africa

Article References: Mmusi, S. M., Bopape, M. A., & Mothiba, T. M. (2026). Integrating climate change adaptation into hypertension care: an evidence based framework for climate resilient primary healthcare and public health planning in Limpopo Province, South Africa. Frontiers in Public Health, 14, Article 1937901. https://doi.org/10.3389/fpubh.2026.1937901

Image Credits: AI Generated

DOI: 10.3389/fpubh.2026.1937901

Keywords: climate change adaptation, hypertension, primary healthcare, South Africa, Limpopo Province, mixed-methods research, Roy's Adaptation Model, Delphi validation, extreme heat, emergency preparedness, public health planning, non-communicable diseases